Why is the mental health burden in EDs rising?

 

The mounting impact of mental illness on patients and the American health care system has been of growing concern, especially in recent years. As such, now more than ever, it is important to understand the mental health burden and investigate the factors contributing to the elevated use of emergency departments to treat patients with psychiatric illness.

In recent years, the overall prevalence of mental illness has not changed drastically. According to the 2014 National Survey of Drug Use and Health, 18.1% of adults indicated having “any mental illness,” a prevalence that had not changed much since 2008.¹ It is possible, however, that despite the relative stability in the prevalence of mental illness, the acuity of mental illness may be on the rise. For instance, 4.1% of adults indicated having a “serious mental illness” (SMI) in 2014, a prevalence that was 0.4% higher than that of 2008 and 2009.¹ Also, of note, the prevalence of SMI among the 18-to-25-year-old population in 2014 had increased in previous years.¹ Meanwhile, 6.6% of adults indicated having experienced a major depressive episode at least once in the preceding 12 months. That prevalence has held relatively steady over recent years.¹

Suicide rates, however, increased steadily by roughly 1% per year between 1999-2006, and by 2% per year between 2006-2014.² Since 1999, suicide has crept up the list of leading causes of death in the United States, from being the fourth leading cause among 10-to-14-year-olds, the third leading cause among 15-to-24-year-olds, and second among 25-to-34-year-olds, to being the second leading cause of death among 10-to-34-year-olds.³

Despite the rising need for mental health services, the number of inpatient psychiatric beds has declined. During the 32 years between 1970 and 2002, the United States experienced a staggering nearly 60% decline in the number of inpatient psychiatric beds.⁴ Moreover, the number of psychiatric beds within the national public sector fell from 50,509 in 2005 to 43,318 in 2010, which is about a 14% decline.⁵ This decrease translated to a decrease from 17.1 beds/100,000 people in 2005 to 14.1 beds/100,000 in 2010 – both of which fall drastically below the “minimum number of public psychiatric beds deemed necessary for adequate psychiatric services (50/100,000).”⁵ Similarly, psychiatric practice has been unable to keep up with the increasing population size – the population-adjusted median number of psychiatrists declined 10.2% between 2003 and 2013.⁶

While inpatient psychiatric beds and psychiatrist availability have declined, the frequency of ED use for mental health reasons has increased. Mental health or substance abuse diagnoses directly accounted for 4.3% of ED visits in 2007 and were associated with 12.5% of ED visits.⁷ Specifically, there was a 19.3% increase in the rate of nonmaternal treat-and-release ED visits for mental health reasons between 2008-2012.⁸ Moreover, in a study assessing frequent treat-and-release ED visits among Medicaid patients, investigators found that while most ED visits were for non–mental health purposes, the odds of frequent ED use were higher among patients with either a psychiatric disorder or substance use problem across all levels of overall health complexity.⁹

A retrospective study completed in Sacramento, Calif., suggests that a decline in county mental health service availability may cause a direct increase in ED use for mental health services. That study looked at what happened when a county mental health treatment center stopped providing outpatient care and cut the number of available psychiatric inpatient beds by half. The result is that the average ED length of stay for psychiatry consultation patients climbed to 21.9 hours after closure, from 14.1 hours before closure. “This phenomenon has important implications for future policy to address the challenges of caring for patients with psychiatric needs in our communities,” the study authors wrote.¹⁰

What factors have been driving adults to increasingly rely on ED visits for their mental health care? Given the immense complexity of the U.S. mental health delivery system, it is evident that there is no clear-cut explanation. However, several specific factors may have contributed and must be investigated to better our understanding of this public health conundrum. The opioid epidemic, transition out of the correctional system, and coverage changes under the Affordable Care Act are hypotheses that will be examined further in the context of this pressing issue.

References

1. “Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health.”

2. “Increase in Suicide in the United States, 1999-2014.” NCHS Data Brief No. 241, April 2016.

3. Web-Based Injury Statistics Query and Reporting System (WISQARS), Centers for Disease Control and Prevention.

4. National Health Policy Forum Issue Brief (2007 Aug 1;[823]:1-21).

5. “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals, 2005-2010,” Arlington, Va.: Treatment Advocacy Center, July 19, 2012.

6. “Population of U.S. Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access to Mental Health Care,” Health Aff (Millwood). 2016 Jul 1;35[7]:1271-7.

7. “Mental Health and Substance Abuse-Related Emergency Department Visits Among Adults, 2007: Statistical Brief #92,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality, 2010).

8. “Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits, 2015: Statistical Brief #195,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality).

9. Nurs Res. 2015 Jan-Feb;64[1]3-12.

10. Ann Emerg Med. 2016 Apr;67[4]:525-30.

 

Ms. Kablanian is a 2nd-year medical student at the George Washington University, Washington, where she is enrolled in the Community and Urban Health Scholarly Concentration Program. Before attending medical school, she earned a master of public health degree in epidemiology from Columbia University, New York. She also holds a bachelor’s degree in biology and French from Scripps College, Claremont, Calif. Her interests include advocating for the urban underserved, contributing to medical curriculum development, and investigating population-level contributors to adverse health outcomes. Dr. Norris is assistant professor in the department of psychiatry & behavioral sciences, and assistant dean of student affairs at the George Washington University. He also is medical director of psychiatric & behavioral sciences at George Washington University Hospital. As part of his commitment to providing mental health care to patients with severe medical illness, Dr. Norris has been a leading voice within the psychiatric community on the value of palliative psychotherapy.

 

The mounting impact of mental illness on patients and the American health care system has been of growing concern, especially in recent years. As such, now more than ever, it is important to understand the mental health burden and investigate the factors contributing to the elevated use of emergency departments to treat patients with psychiatric illness.

In recent years, the overall prevalence of mental illness has not changed drastically. According to the 2014 National Survey of Drug Use and Health, 18.1% of adults indicated having “any mental illness,” a prevalence that had not changed much since 2008.¹ It is possible, however, that despite the relative stability in the prevalence of mental illness, the acuity of mental illness may be on the rise. For instance, 4.1% of adults indicated having a “serious mental illness” (SMI) in 2014, a prevalence that was 0.4% higher than that of 2008 and 2009.¹ Also, of note, the prevalence of SMI among the 18-to-25-year-old population in 2014 had increased in previous years.¹ Meanwhile, 6.6% of adults indicated having experienced a major depressive episode at least once in the preceding 12 months. That prevalence has held relatively steady over recent years.¹

Suicide rates, however, increased steadily by roughly 1% per year between 1999-2006, and by 2% per year between 2006-2014.² Since 1999, suicide has crept up the list of leading causes of death in the United States, from being the fourth leading cause among 10-to-14-year-olds, the third leading cause among 15-to-24-year-olds, and second among 25-to-34-year-olds, to being the second leading cause of death among 10-to-34-year-olds.³

Despite the rising need for mental health services, the number of inpatient psychiatric beds has declined. During the 32 years between 1970 and 2002, the United States experienced a staggering nearly 60% decline in the number of inpatient psychiatric beds.⁴ Moreover, the number of psychiatric beds within the national public sector fell from 50,509 in 2005 to 43,318 in 2010, which is about a 14% decline.⁵ This decrease translated to a decrease from 17.1 beds/100,000 people in 2005 to 14.1 beds/100,000 in 2010 – both of which fall drastically below the “minimum number of public psychiatric beds deemed necessary for adequate psychiatric services (50/100,000).”⁵ Similarly, psychiatric practice has been unable to keep up with the increasing population size – the population-adjusted median number of psychiatrists declined 10.2% between 2003 and 2013.⁶

While inpatient psychiatric beds and psychiatrist availability have declined, the frequency of ED use for mental health reasons has increased. Mental health or substance abuse diagnoses directly accounted for 4.3% of ED visits in 2007 and were associated with 12.5% of ED visits.⁷ Specifically, there was a 19.3% increase in the rate of nonmaternal treat-and-release ED visits for mental health reasons between 2008-2012.⁸ Moreover, in a study assessing frequent treat-and-release ED visits among Medicaid patients, investigators found that while most ED visits were for non–mental health purposes, the odds of frequent ED use were higher among patients with either a psychiatric disorder or substance use problem across all levels of overall health complexity.⁹

A retrospective study completed in Sacramento, Calif., suggests that a decline in county mental health service availability may cause a direct increase in ED use for mental health services. That study looked at what happened when a county mental health treatment center stopped providing outpatient care and cut the number of available psychiatric inpatient beds by half. The result is that the average ED length of stay for psychiatry consultation patients climbed to 21.9 hours after closure, from 14.1 hours before closure. “This phenomenon has important implications for future policy to address the challenges of caring for patients with psychiatric needs in our communities,” the study authors wrote.¹⁰

What factors have been driving adults to increasingly rely on ED visits for their mental health care? Given the immense complexity of the U.S. mental health delivery system, it is evident that there is no clear-cut explanation. However, several specific factors may have contributed and must be investigated to better our understanding of this public health conundrum. The opioid epidemic, transition out of the correctional system, and coverage changes under the Affordable Care Act are hypotheses that will be examined further in the context of this pressing issue.

References

1. “Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health.”

2. “Increase in Suicide in the United States, 1999-2014.” NCHS Data Brief No. 241, April 2016.

3. Web-Based Injury Statistics Query and Reporting System (WISQARS), Centers for Disease Control and Prevention.

4. National Health Policy Forum Issue Brief (2007 Aug 1;[823]:1-21).

5. “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals, 2005-2010,” Arlington, Va.: Treatment Advocacy Center, July 19, 2012.

6. “Population of U.S. Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access to Mental Health Care,” Health Aff (Millwood). 2016 Jul 1;35[7]:1271-7.

7. “Mental Health and Substance Abuse-Related Emergency Department Visits Among Adults, 2007: Statistical Brief #92,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality, 2010).

8. “Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits, 2015: Statistical Brief #195,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality).

9. Nurs Res. 2015 Jan-Feb;64[1]3-12.

10. Ann Emerg Med. 2016 Apr;67[4]:525-30.

 

Ms. Kablanian is a 2nd-year medical student at the George Washington University, Washington, where she is enrolled in the Community and Urban Health Scholarly Concentration Program. Before attending medical school, she earned a master of public health degree in epidemiology from Columbia University, New York. She also holds a bachelor’s degree in biology and French from Scripps College, Claremont, Calif. Her interests include advocating for the urban underserved, contributing to medical curriculum development, and investigating population-level contributors to adverse health outcomes. Dr. Norris is assistant professor in the department of psychiatry & behavioral sciences, and assistant dean of student affairs at the George Washington University. He also is medical director of psychiatric & behavioral sciences at George Washington University Hospital. As part of his commitment to providing mental health care to patients with severe medical illness, Dr. Norris has been a leading voice within the psychiatric community on the value of palliative psychotherapy.

 

The mounting impact of mental illness on patients and the American health care system has been of growing concern, especially in recent years. As such, now more than ever, it is important to understand the mental health burden and investigate the factors contributing to the elevated use of emergency departments to treat patients with psychiatric illness.

In recent years, the overall prevalence of mental illness has not changed drastically. According to the 2014 National Survey of Drug Use and Health, 18.1% of adults indicated having “any mental illness,” a prevalence that had not changed much since 2008.¹ It is possible, however, that despite the relative stability in the prevalence of mental illness, the acuity of mental illness may be on the rise. For instance, 4.1% of adults indicated having a “serious mental illness” (SMI) in 2014, a prevalence that was 0.4% higher than that of 2008 and 2009.¹ Also, of note, the prevalence of SMI among the 18-to-25-year-old population in 2014 had increased in previous years.¹ Meanwhile, 6.6% of adults indicated having experienced a major depressive episode at least once in the preceding 12 months. That prevalence has held relatively steady over recent years.¹

Suicide rates, however, increased steadily by roughly 1% per year between 1999-2006, and by 2% per year between 2006-2014.² Since 1999, suicide has crept up the list of leading causes of death in the United States, from being the fourth leading cause among 10-to-14-year-olds, the third leading cause among 15-to-24-year-olds, and second among 25-to-34-year-olds, to being the second leading cause of death among 10-to-34-year-olds.³

Despite the rising need for mental health services, the number of inpatient psychiatric beds has declined. During the 32 years between 1970 and 2002, the United States experienced a staggering nearly 60% decline in the number of inpatient psychiatric beds.⁴ Moreover, the number of psychiatric beds within the national public sector fell from 50,509 in 2005 to 43,318 in 2010, which is about a 14% decline.⁵ This decrease translated to a decrease from 17.1 beds/100,000 people in 2005 to 14.1 beds/100,000 in 2010 – both of which fall drastically below the “minimum number of public psychiatric beds deemed necessary for adequate psychiatric services (50/100,000).”⁵ Similarly, psychiatric practice has been unable to keep up with the increasing population size – the population-adjusted median number of psychiatrists declined 10.2% between 2003 and 2013.⁶

While inpatient psychiatric beds and psychiatrist availability have declined, the frequency of ED use for mental health reasons has increased. Mental health or substance abuse diagnoses directly accounted for 4.3% of ED visits in 2007 and were associated with 12.5% of ED visits.⁷ Specifically, there was a 19.3% increase in the rate of nonmaternal treat-and-release ED visits for mental health reasons between 2008-2012.⁸ Moreover, in a study assessing frequent treat-and-release ED visits among Medicaid patients, investigators found that while most ED visits were for non–mental health purposes, the odds of frequent ED use were higher among patients with either a psychiatric disorder or substance use problem across all levels of overall health complexity.⁹

A retrospective study completed in Sacramento, Calif., suggests that a decline in county mental health service availability may cause a direct increase in ED use for mental health services. That study looked at what happened when a county mental health treatment center stopped providing outpatient care and cut the number of available psychiatric inpatient beds by half. The result is that the average ED length of stay for psychiatry consultation patients climbed to 21.9 hours after closure, from 14.1 hours before closure. “This phenomenon has important implications for future policy to address the challenges of caring for patients with psychiatric needs in our communities,” the study authors wrote.¹⁰

What factors have been driving adults to increasingly rely on ED visits for their mental health care? Given the immense complexity of the U.S. mental health delivery system, it is evident that there is no clear-cut explanation. However, several specific factors may have contributed and must be investigated to better our understanding of this public health conundrum. The opioid epidemic, transition out of the correctional system, and coverage changes under the Affordable Care Act are hypotheses that will be examined further in the context of this pressing issue.

References

1. “Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health.”

2. “Increase in Suicide in the United States, 1999-2014.” NCHS Data Brief No. 241, April 2016.

3. Web-Based Injury Statistics Query and Reporting System (WISQARS), Centers for Disease Control and Prevention.

4. National Health Policy Forum Issue Brief (2007 Aug 1;[823]:1-21).

5. “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals, 2005-2010,” Arlington, Va.: Treatment Advocacy Center, July 19, 2012.

6. “Population of U.S. Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access to Mental Health Care,” Health Aff (Millwood). 2016 Jul 1;35[7]:1271-7.

7. “Mental Health and Substance Abuse-Related Emergency Department Visits Among Adults, 2007: Statistical Brief #92,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality, 2010).

8. “Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits, 2015: Statistical Brief #195,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality).

9. Nurs Res. 2015 Jan-Feb;64[1]3-12.

10. Ann Emerg Med. 2016 Apr;67[4]:525-30.

 

Ms. Kablanian is a 2nd-year medical student at the George Washington University, Washington, where she is enrolled in the Community and Urban Health Scholarly Concentration Program. Before attending medical school, she earned a master of public health degree in epidemiology from Columbia University, New York. She also holds a bachelor’s degree in biology and French from Scripps College, Claremont, Calif. Her interests include advocating for the urban underserved, contributing to medical curriculum development, and investigating population-level contributors to adverse health outcomes. Dr. Norris is assistant professor in the department of psychiatry & behavioral sciences, and assistant dean of student affairs at the George Washington University. He also is medical director of psychiatric & behavioral sciences at George Washington University Hospital. As part of his commitment to providing mental health care to patients with severe medical illness, Dr. Norris has been a leading voice within the psychiatric community on the value of palliative psychotherapy.